Clinical Quality: 2019 Medicare Star Rating Update

The Centers for Medicare and Medicaid Services (CMS) recently announced STAR rating measures for 2019, with improvements in clinical quality as the focus of patient care. Success in 2019 is going to be highly dependent on pharmacies knowing the quality metrics that require continued focus to drive 5-star thresholds.  As your partner in excellence, the clinical team at Pharmacy First has identified key quality metrics for 2019 and is here to support pharmacies in their clinical success.

Continued Focus on Adherence

The healthcare community understands the value of patient adherence on clinical outcomes and overall healthcare spend. Adherence continues to be at the forefront of clinical quality metrics, with the majority of 5-star adherence cut offs increasing in 2019. In order to be a top performer, plans must achieve adherence scores ranging from 85-89% for diabetes, hypertension, and cholesterol medications.

Maintaining patient adherence requires a multifaceted approach that begins with visibility to pharmacy performance data. Engaging EQuIPP on a weekly basis allows pharmacies to proactively monitor any late to fill patients and quickly act upon any outliers. When discussing adherence with patients, Pharmacy First recommends utilizing motivational interviewing with patients to understand barriers to care, and mediation synchronization and adherence packaging solutions to maximize patient success.

Comprehensive Medication Review (CMR) Completion

CMR completion rates experienced the largest increase in quality metric cut-points, with Part-D 5-star performance climbing nearly 20 percentage points to 72%. As a result, it’s imperative for pharmacies to routinely monitor CMR opportunities and engage eligible patients. Performing CMRs allows pharmacists dedicated time to engage with patients and identify any drug related problems, while simultaneously bringing in additional revenue for completion.

Pharmacies can complete CMRs on a variety of MTM platforms, including OutcomesMTM, Optum MedMonitor, and Mirixa. It is essential for pharmacies to be active on all three platforms, as utilization differs by payer. If your pharmacy needs assistance in enrolling in one of the many MTM platforms, the Pharmacy First customer service team is ready to assist.


Cardiovascular Care

In order to reduce the risk of cardiovascular events, CMS has added two new metrics to the 2019 Star Rating criteria. In 2019, statin use in patients age 40-75 with a history diabetes will be a weighted measure for both Medicare Part D and Medicare Advantage plans. Plans must reach a performance score of 82-83% to be a five-star performer and a champion of cardiovascular care. Additionally, CMS is monitoring statin use in patients with a history of cardiovascular disease for Medicare Advantage patients. In order to reach 5-stars, plans must have at least 85% of patients on a statin.

Statin use in these populations is critical to prevent potentially life-threatening cardiovascular events. Pharmacies are encouraged to utilize platforms, such as EQuIPP, to identify patients with current gaps in care. Many health plans recognize the importance of statin use and may provide paid MTM opportunities to engage patients and providers.



As your partner in excellence, Pharmacy First has a team of licensed clinical pharmacists who provide complimentary quality review sessions to members. Our pharmacists’ real-world experience, coupled with in-house data analytics, allows Pharmacy First to provide expert guidance on improving clinical outcomes in a manner that doesn’t compromise operational efficiency.

Our clinical pharmacists, Todd Wormington and Katelyn Strauch, are passionate about independent pharmacy and dedicated to your pharmacy’s success. Connect with our clinical pharmacists to schedule a one-on-one time to review your pharmacy’s current performance and create a strategic plan to maximize clinical quality metrics. For more information, or to schedule a clinical quality review, call 800.460.1575 x301 or email

About the Author

Todd Wormington is the Director, Pharmacy Programs for Pharmacy First and has over 25 years of pharmacy industry experience. His work as a practicing pharmacist helped frame a passion for direct patient care and led to a career focused on the clinical and operational resources required to deliver enhanced pharmacy services in a community-based setting.